<div class="fpzb_bt">
	<h1>手机咨询预约挂号平台</h1>
</div>
<div class="fpzb_gh">
	<p>
		广州中医药大学金沙洲医院
		<br>贯彻执行卫生部网上咨询挂号服务</p>
</div>
<script type="text/javascript" src="/templets/phone/js/online.js"></script>
<form style="width:94%;margin:0 auto; border:1px solid #aaaaaa" method="post" action="http://mail.jszjrzk.com/bmi/phone" name="myform" id="myform">
	<div class="table">
		<table class="table_form" width="100%" cellspacing="0">
			<tbody>
				<tr>
					<th width="80"> <font color="red"></font>
						姓名
					</th>
					<td>
						<input type="text" name="name" id="name" size="23" value="" class="input-text" fpzb_xingm=""></td>
				</tr>
				<tr>
					<th width="80"> <font color="red"></font>
						年龄
					</th>
					<td>
						<input type="text" name="age" id="age" size="23" value="" class="input-text" fpzb_xingm=""></td>
				</tr>
				<tr>
					<th width="80">
						<font color="red"></font>
						电话
					</th>
					<td>
						<input type="text" name="phone" id="phone" size="23" value="" class="input-text" fpzb_xingm=""></td>
				</tr>
				<tr>
					<th width="80">
						<font color="red"></font>
						日期
					</th>
					<td>
						
						<input type="date" name="date" id="date" value="" size="10" class="date" >
						&nbsp;
					</td>
				</tr>
				<tr>
					<th width="80">
						<font color="red"></font>
						预约病种
					</th>
					<td>
						<select name="entity" id="entity">
							<option value="肥胖症">肥胖症</option>
							<option value="糖尿病">糖尿病</option>
						</select>
					</td>
				</tr>
				<tr>
					<th width="80">
						<font color="red"></font>
						在线预约
					</th>
					<td>
						<select name="team" id="team">
							<option value="戴晓江">戴晓江</option>
							<option value="黄宗海">黄宗海</option>
						</select>
					</td>
				</tr>
			</tbody>
		</table>
		<div class="fpzb_xingm">
			<input class="zaixian1 sub_btn" type="button" name="dosubmit" id="dosubmit" value="提交挂号">
			<div class="zaixian">
				<a target="_blank" onclick="openZoosUrl();LR_HideInvite();return false;" rel="nofollow" href="javascript:void(0)">在线预约</a>
			</div>
			<div class="clear"></div>
		</div>
		<div class="fpzb_ts1">温馨提示：网站网页已加密，严格保障患者隐私。因来院患者较多，请提前预约挂号。</div>
	</div>
</form>